Wound Assessment form
PDF
Download the Triangle of Wound Assessment
2
pages
Get full access with a free account
Benefits of the Coloplast® Professional Educational platform
- Get full access to all educational content, events and resources
- Track your progress
- Share content with your collegues
- Share supporting material with your patient
Before conducting a wound assessment, it's essential to recognise the signs of underlying arterial or venous disease. Understanding these indicators helps guide appropriate treatment decisions. For a deeper look at key risk factors and clinical signs to watch for, refer to the understanding leg ulcer section.
A full lower limb assessment, diagnosis and treatment plan should be completed within 14 days or in conjunction with your local policy.
Following a full lower limb assesment including an Ankle Brachial Pressure index, patients with suspected venous leg ulcers and adequate arterial supply, strong compression of 40mmHg therapy should be offered.
Personalised care is essential, including discussing causes, treatment options and supporting self‑management. Clear referral pathways should also be in place to allow direct access to relevant specialists without needing a GP referral.
Assess the wound bed: - Measure the wound depth
- Assess what tissue types can be observed i.e. slough, necrosis.
- Check for exudate pooling
- Determine the amount of wound exudate in both wound and dressing (how saturated is the dressing?).
- Assess the colour, viscosity and odour of the wound exudate.
- Measure the wound depth
- Assess what tissue types can be observed i.e. slough, necrosis.
- Check for exudate pooling
- Determine the amount of wound exudate in both wound and dressing (how saturated is the dressing?).
- Assess the colour, viscosity and odour of the wound exudate.
How deep is the wound?
Was the previous dressing the most appropriate?
Do you see exudate pooling?
Assess the wound edge and periwound skin:
- Assess the wound edges (are they attached, rolled, inflamed, undermined, advancing, macerated?).
- Assess the periwound skin (is it intact, fragile, inflamed, macerated?).
Is the wound edge and periwound skin macerated?
Is the wound edge undermined?
Are there rolled wound edges?
Triangle of Wound Assessment
Wound Assessment can be complex with reasons for this being multifactorial. Using a simplified wound assessment framework such as the Triangle of Wound Assessment can help simplify the process.
- Frequency of wound assessment will depend on the condition of the patient, the condition of the wound and the care setting
- A holistic wound assessment should, as a minimum, be: Every two weeks in an acute setting, or, every four weeks within a primary care and community setting.
Always look for signs of lymphoedema/lympho-venous disease as part of your clinical assessment
Ankle Brachial Pressure Index (ABPI)
The Ankle Brachial Pressure Index (ABPI) is a quick, non‑invasive test that checks how well blood is flowing to the legs and feet.
It works by comparing two blood pressure readings:
- one taken at the arm (brachial pressure)
- one taken at the ankle
Then the ankle pressure is divided by the arm pressure to give a number — the ABPI.
What the number tells you
- A normal ABPI means good blood flow to the legs.
- A low ABPI suggests narrowed or blocked arteries, which may affect healing.
- A high ABPI can indicate stiff or calcified arteries, often seen in people with diabetes.
Why it matters
Understanding ABPI helps clinicians decide:
- whether compression therapy is safe
- how well a wound (like a leg ulcer) is likely to heal
- whether further vascular assessment is needed
ABPI values should always be interpreted in context of signs and symptoms.
Less than 0.5 suggests severe arterial disease
- Compression treatment is contraindicated
- Refer for an urgent vascular assessment
Between 0.8 and 1.3 suggests no evidence of significant arterial disease
- Compression may be applied safely for most people
Greater than 1.3 suggest arterial calcification
- Compression may be used with caution
- Refer for a vascular assessment
Greater than 0.5 to less than 0.8 suggests the presence of arterial disease or mixed arterial/venous disease
- Compression should be avoided but reduced compression could be used under specialist advice
- Refer for a vascular assessment
1. NICE (2021) How should I interpret ankle brachial pressure index (ABPI) results? Available at: Interpretation of ABPI | Diagnosis | Leg ulcer - venous | CKS | NICE
The aim of wound preparation is to accelerate healing or to facilitate the effectiveness of management and treatment plans. It is an approach that should be undertaken at each wound care intervention. When planning to prepare the wound you need to take into consideration:
- Assessment
- Clinical judgement
- Treatment goals
- Pain levels
When should we be cautious with wound preparation?
- If a patient has a wound on a lower limb and is known to be diabetic (this may be suitable but will require specialist advice).
- If a patient has a known arterial flow concern or poor localised tissue perfusion.
- If healing ability is impaired because of medications or underlying medical condition (e.g. cytoxic medications, immunosurpressed).
- Malignancy / Fungating wounds
Learn more about the importance of wound preparation, different debridement methods, and effectively using Alprep Pad for mechanical debridement.
“
"It's not what we put on the wound that heals it; it's what we take off"
Donna Welch
Podiatry Operations Manager
How to develop a treatment and care plan
Once your diagnosis of the leg has excluded arterial insufficiency, you are ready to determine the need for any additions to the standard treatment planning procedure.
Be prepared to manage exudate to protect the periwound skin, as venous leg ulcers are often highly exudating. (This will reduce over time with the correct level of compression therapy).
Frequently undertake a patient reported pain assessment, as leg ulcers are ranked as the most painful compared to other wounds.1
You should proceed according to the result of your ABPI:
- In case your ABPI is more than 0.8, arterial, involvement can be ruled out and compression therapy can be considered at 40mmHg.
- In case your ABPI is between 0.5 and 0.8 refer for advice regarding level of compression.
- In case your ABPI is less than 0.5 do not compress and refer immediately for vascular assessment.
The concept of compression therapy
➔ Choose the correct type of compression by taking relevant factors into account: The severity of the disease, the anatomical characteristic of the leg/ankle, required frequency of applications, and the functionality of the patient: Patient preference, mobility, lifestyle and likely concordance.2
➔ Check for signs of infection at each dressing change, as infection and biofilm are common in venous leg ulcers. Use the IWII infection continuum and management guide.
Identifying treatment objectives
Wound assessment and preparation leads to identification of objectives. We should aim to support an optimum healing environment for the wound.
Remember – Identifying and treatment of any underlying cause is integral to wound healing!
What is your treatment objective? Consider the following:
Management / prevention of...
- Exudate or exudate pooling
- Protection of the peri-wound skin
- Maceration or excoriation
- Depth or cavity to the wound
- Infection
The National Wound Care Strategy Programme recommends the application of a simple, low-adherent dressing with sufficient absorbency.
There are various dressing types available to us as clinicians, knowing what each does is essential.
Commonly used dressings can be broken down into categories:
No infection present
For use under Compression Hosiery / Leg Wraps
)
Biatain® Silicone or Biatain® Silicone Lite
Conforms to the wound bed
Absorbs vertically
Retains exudate
Biatain Silicone with 3DFit Technology improves healing by conforming to the shape of the wound up to 2 cm deep*. This creates an optimal wound healing environment that reduces leakage along with the risk of maceration and infection.
*Tested in vitro, Conformability may vary across product design
No infection present
For use under Compression Bandaging
)
Biatain® Silicone Non-Border
Conforms to the wound bed
Absorbs vertically
Retains exudate
Biatain® Silicone Non-Border consists of a soft and conformable polyurethane foam with a vapour permeable top film that is bacteria- and waterproof, a gentle and perforated silicone adhesive, and turquoise protective films.
)
Biatain® Non-Adhesive
Unique 3D foam structure for superior absorption
Minimised risk of maceration and leakage (1)
Long wear time
Biatain® Non-Adhesive is a soft and conformable polyurethane foam dressing that effectively absorbs and retains wound exudate (1,2).
)
Biatain® Superabsorber
Biatain Superabsorber provides optimised absorption and retention
Biatain® Superabsorber is a soft, non-adhesive dressing that can manage high volumes of exudate, whilst protecting the wound edges and delicate peri-wound skin from maceration.
Infection present
For use under Compression Hosiery / Leg Wraps
)
Biatain® Silicone Ag
Absorbs vertically
Conforms to the wound bed
Traps and retains bacteria
Biatain Silicone Ag is a conforming dressing with 3DFit Technology that fills the gap and reduces exudate pooling to promote optimal healing conditions.
)
Biatain Ag Non Adhesive
Biatain® Ag Non-Adhesive can be used for a wide range of exuding wounds with delayed healing due to bacteria, or where there is a risk of infection
Patient experiencing pain
For use either under Compression Hosiery / Leg Wraps or Compression Bandaging
)
Biatain® Ibu
Biatain® Ibu Soft-Hold is a soft and flexible absorbent foam dressing containing ibuprofen and a gentle adherent layer covering less than 50% of the foam surface (1).
Strong compression therapy for suspected venous disease with an adequate arterial supply
Hosiery kits for active ulcers:
- A type of medical compression therapy most commonly used for the management and healing of venous leg ulceration
- Kits consist of two medical compression garments designed to be worn one on top of the other
- Most kits contain two liners and one stocking
- Designed to deliver 40mmHg of pressure at the ankle reducing to 20mmHg at the calf
- Recommendation is to be worn for 24 hours but outer layer to be removed at night
- Available in off-the-shelf forms or made to measure